37.84.107    HELP ACT: PREMIUMS

(1) A HELP participant must pay a premium equal to two percent of the prorated share of the participant's annual household income. The premium will be billed in twelve equal monthly amounts.

(2) Except as provided in subsection (3), the premiums must:

(a) be set at 2% of a participant's income in the first two years the participant received coverage; and

(b) increase by 0.5% in each consecutive subsequent year that a participant receives coverage, up to a maximum of 4% of the participant's income.

(3) A participant who is exempt from the community engagement activity participation requirements as allowed under ARM 37.84.119, 37.84.120, and 37.84.121 is exempt from the premium increases in (2)(b).

(4) A participant, except as provided in (6) and (7), for whom an overdue premium is owed, will be disenrolled from coverage as provided in (5).

(5) The process for collection of overdue premiums is as follows:

(a) Within 30 days of the date a participant's premium payment was due, the department must notify the participant that the payment is overdue and that all overdue premiums must be paid within 90 days of the date the notification was sent.

(b) If payment for overdue premiums is not received, the department will notify the Department of Revenue of the sum owed.

(c) Unless the participant states the intent not to reenroll, the department may reenroll the person in the HELP Plan when the Department of Revenue assesses the unpaid premium through the participant's income tax.

(6) A participant who has an annual household income below 100 percent of the current FPL is not subject to disenrollment due to nonpayment of a premium.

(7) A participant is not subject to disenrollment for failure to pay a premium if the participant meets two of the following criteria:

(a) discharge from the United States military within the previous 12 months;

(b) enrollment in any Montana university system unit, a tribal college, or an accredited Montana college offering at least an associate degree. A participant cannot claim the education exemption for more than four years;

(c) participation in a workforce program or activity established under the authority of 39-12-101 through 39-12-107, MCA; or

(d) participation in any of the following health behavior activities developed by a health care provider or approved by the department:

(i) a Medicaid health home;

(ii) a patient-centered medical home;

(iii) a cardiovascular disease, obesity, or diabetes prevention program;

(iv) a program requiring the member to obtain primary care services from a designated provider and to obtain prescriptions from a designated pharmacy;

(v) a Medicaid primary care case-management program established by the department;

(vi) a tobacco use prevention or cessation program; or

(vii) a substance abuse treatment program.

(8) A participant may reenroll at any time by payment of the premium.

(9) A participant is exempt from paying a premium if the individual:

(a) has a modified adjusted gross income under 50% of the federal poverty level;

(b) has been determined to be medically frail;

(c) is American Indian or Alaska Native;

(d) is receiving Medicaid services under a presumptive eligibility program; or

(e) is pregnant.

(10) The department shall implement and enforce (2) and (3) only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.


History: 53-2-215, 53-6-113, 53-6-1318, MCA; IMP, 53-2-215, 53-6-101, 53-6-1307, MCA; NEW, 2015 MAR p. 2294, Eff. 1/1/16; AMD, 2017 MAR p. 2326, Eff. 1/1/18; AMD, 2020 MAR p. 2438, Eff. 1/1/21.